The member will not be held financially responsible for the cost of noncovered services except for any
applicable copayment, coinsurance, or deductible if the noncovered services are rendered before the
member receives an organization determination from BCBSNC denying coverage.

In either instance, the participating provider will be advised that they must write-off the cost of the non-certified or noncovered services and hold the member financially harmless according to contract provisions.

Ancillary services provided in conjunction with non-precertified services are also not payable by the Plan unless the ancillary provider is a non-participating provider.

This policy will also apply when Plan is the secondary payer of claims.

Members will be held responsible for non-certified services when the member receives an organization
determination from BCBSNC denying coverage before the services are rendered.

Blue Cross and Blue Shield of North Carolina is an HMO, PPO, and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. Blue Cross and Blue Shield of North Carolina does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.